Social disparities in maternal, child, and reproductive health:

1. Social disparities in maternal, child, and reproductive health: Work of the Center on Social Disparities in Health

2. Healthy People 2010 �Achieving Equity� The Healthy People Perspective� �Healthy People 2010 is firmly dedicated to the principle that � regardless of age, gender, race, ethnicity, income, education, geographic location, disability, and sexual orientation� every person� deserves equal access to�health care systems�� HP2010 Vol. 1, p. 16

3. Healthy People 2010 �Achieving Equity� The Healthy People Perspective� �HP 2010 recognizes that communities, States, and national organizations will need to take a multidisciplinary approach to achieving health equity that involves improving health, education, housing, labor, justice, transportation, agriculture, and the environment.� HP2010 Vol. 1, p. 16

4. Goals of the Center on Social Disparities in Health Address HP 2010 objectives Address the need for better information � and better use of existing information � to guide efforts to reduce disparities Studies, ongoing monitoring, dissemination: inform policies to close gaps Training U.S. focus with international links

5. Social disparities in health �Health disparities� Health differences between more and less advantaged social groups underlying advantage, position in social hierarchy E.g. groups specified in HP 2010: socioeconomic, racial/ethnic, geographic, age, disability, sexual orientation, and other

6. Why care about health disparities? Ethical principles � justice Consonant with human rights principles non-discrimination rights to health/living standards Disparities that put already disadvantaged groups at further disadvantage on health Equal opportunity to be healthy implies concern for disparities in health and its social determinants

7. Why a center at UCSF? Two decades of work on disparities by core faculty (research and informing policy) Leadership in US and internationally in placing health equity on agenda, developing methods, contributing to knowledge base Core faculty expertise on maternal, infant, child, adolescent, and reproductive health Local expertise available to expand National and international networks

8. Core faculty Paula Braveman Paul Newacheck Catherine Cubbin Susan Egerter Kristen Marchi Claire Brindis Dana Hughes Geraldine Oliva UCSF Departments of Family and Community Medicine and Pediatrics UCSF Institute for Health Policy Studies

9. Affiliated faculty, e.g.: Art Reingold Sylvia Guendelman Len Syme Marilyn Winkleby Eliseo Perez-Stable Eugene Washington Nancy Adler Ed Yelin UC Berkeley School of Public Health Stanford University UCSF

10. Current activities MIHA and PRAMS: develop, apply, and disseminate methods for research and ongoing state-level monitoring of disparities NHIS (1984-01): trends in child and adolescent health disparities; methods for ongoing monitoring Add Health: individual, household, and contextual factors in disparities in adolescent reproductive health behaviors Compare trends in health-related spending on children vs adults

11. Early products Methods for research and ongoing monitoring Measuring SES � PH Reports �2001�/2002 Monitoring health equity -- under review, JHNP Model for state-level monitoring--Kaiser Policy Brief, in press; submitting paper to AJPH Inform interventions Kaiser Policy Brief (3 outcomes) Analyses re LBW/PTB Cubbin et al., 2002 MCHJ - unintended childbearing Under review: Heck et al., breastfeeding (AJPM); Chung et al., sleep position (Amb Peds)

12. Measuring SES in studies of racial/ethnic disparities: Examples from maternal and infant health Paula Braveman, Catherine Cubbin, Kristen Marchi, Susan Egerter, Gilberto Chavez Published in Public Health Reports during 2002 (�2001�) Special Issue on Health Disparities

13. Purpose Guide how �SES� is measured in studies of racial/ethnic disparities in: LBW, delayed/no prenatal care, unintended childbearing, and breastfeeding intention Focus on income and education, the measures used most in US Address general public health audience

14. Concerns �SES� used throughout health literature but rarely defined Diverse measures used without justifying why selected, how and when measured, or how interpreted Conclusions about role of SES can vary based on above

15. What do we mean by �SES�? Socioeconomic status/position Wealth-- and/or the associated power and social standing/prestige Income, accumulated economic assets (wealth) Education (prestige, wealth, power) Occupation (power, prestige, wealth) Multidimensional construct -- yet health studies often use a single SES measure

16. Without adequate SES measurement... Can�t assess role of SES in health or its contribution to other associations, e.g., between race/ethnicity and health Racial/ethnic disparities often interpreted to reflect biological or �cultural� differences without adequately considering SES role

17. Methods Large (n > 10,000) statewide representative face-to-face postpartum survey in random sample of 19 California delivery hospitals, 1994-95 English and Spanish Linked with birth certificates and census data Sample characteristics similar to statewide population

18. Terms SES dimensions: different general constructs: income/wealth, education, occupation Ways of specifying SES constructs e.g.: income; income as a % of poverty level; income per family size (more specific construct) continuous vs categorical (and how categorized) level: maternal, paternal, household, community timing in life cycle

19. Individual-/household-level SES measures: Income Before-tax family income % of federal poverty level in 5 categories continuous (log income in dollars) quartiles based on continuous income continuous income per family size quartiles based on income per family size Information missing for only 5%

20. Educational attainment �Household education�: schooling of the most educated parent Schooling in years (maternal, paternal, household) source: birth certificate Maternal, paternal, household schooling in levels: source: maternal level from survey paternal level estimated from years in birth certificate

21. Race/ethnicity Social construct Region of family origin and/or associated superficial physical characteristics, which could influence experiences and responses Mutually exclusive categories African American Asian/Pacific Islander European American Latina

22. Outcome measures LBW delayed or no prenatal care unintended childbearing (not trying) Not intending to breastfeed when interviewed in delivery hospital

23. Other variables Age (years) and parity (1, 2-4, 5+ births) could confound associations between SES measures and health outcomes But age and parity could be on causal pathway between an SES measure and a health outcome so their inclusion could diminish observed association and mislead on role of SES